STATE OF TENNESSEE...–Well-child visits ages 3- 6 years (W34); included as stand-alone metric for Family practices Threshold set at > 65% • CY2019 Composite metric for Family and

2019 PCMH Program Enhancements

11/27/2018

STATE OF TENNESSEE

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Agenda

• 2018 PCMH Statistics and Accomplishments

• 2019 PCMH Quality Metric Sets and Thresholds

• 2019 TCOC Value for Low Volume PCMH Outcome Payment Formula

• Reporting Timeframes

• Updates on Program Guidance

• Navigant Update

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2018 PCMH Statistics and Accomplishments

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2018 statistics for wave 1 & 2 organizations

The MCOs are expected to have all contracting completed by the end of December 2018. A full list of organizations will be released after all contracting has been completed.

Wave 1 Wave 2 Total

Number of PCMHs 28 39 67

Total number of members

248,976 233,098 467,074

Number of sites 177 246 423

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2018 PCMH accomplishments

• Nineteen wave 1organizations earned an outcome payment

• Ten Wave 1 organizations (covering 37 sites) achieved NCQA PCMH Recognition under 2017 standards since beginning program participation

• Overall, 37 wave 1 and 2 PCMH organizations, covering 223 sites, have NCQA PCMH recognition • Recognition across the sites represent a combination of

accreditation under 2011, 2014 and 2017 NCQA standards

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2018 Care Coordination Tool achievements

• Admission, Discharge, and Transfer (ADT) feeds continue to be a significant data source for the PCMH and THL programs

• To date, 88% of hospitals and licensed hospital beds statewide are submitting ADT data

ADT feeds from hospitals across the state in near real-time

• September: All 9 Covenant facilities from East Tennessee Health Information Network (etHIN) are now Live

• December: All Tennova/CHS facilities to go Live

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2019 PCMH Quality Metric Sets and Thresholds

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CY2019 Adult PCMH core quality metrics

Metric Threshold

1. Antidepressant medication management (AMM)-continuation phase

> 40%

2. Comprehensive diabetes care: BP control < 140/90

> 56%

3. Comprehensive diabetes care: Eye exam (retinal) performed

> 51%

4. Comprehensive diabetes care: HbA1c poor control (>9.0%)

< 47%

5. EPSDT: Adolescent well-care visits ages 12-21 years

> 47%

CY2019 Pediatric PCMH core quality metrics

Metric Threshold

1. Asthma medication ratio (AMR) > 81%

2. Childhood immunizations (CIS)-Combination 10

> 42%

3. ESPDT (Composite for older kids)-Well-child visits ages 7-11 years (custom)-Adolescent well-care visits ages 12-21 years (AWC)

> 55%

> 47%

4. EPSDT screening rate (Composite for younger kids)-Well-child visits first 15 months (W15)-Well-child visits at 18, 24, & 30 months (custom)-Well-child visits ages 3-6 years (W34)

> 61%

> 34%

> 69%

5. Immunizations for adolescents-Combination 2

> 26%

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CY2019 Family PCMH core quality metrics

Metric Threshold

1. Antidepressant medication management 47% (AMM)- continuation phase > 40%

2. Asthma medication ratio (AMR) > 81%

3. BMI composite-Adult BMI assessment (ABA)-Weight assessment and counseling for nutrition for children/adolescents (WCC) - BMI percentile only

> 83%> 66%

4. Childhood immunizations (CIS)- Combination 10 > 42%

5. Comprehensive diabetes care: BP control < 140/90 > 56%

6. Comprehensive diabetes care: Eye exam (retinal) performed > 51%

7. Comprehensive diabetes care: HbA1c poor control (>9.0%) < 47%

8. ESPDT (Composite for older kids)-Well-child visits ages 7-11 years (custom)-Adolescent well-care visits ages 12-21 years (AWC)

> 55%> 47%

9. EPSDT screening rate (Composite for younger kids)-Well-child visits first 15 months (W15)-Well-child visits at 18, 24, & 30 months (custom)-Well-child visits ages 3-6 years (W34)

> 61%> 34%> 69%

10. Immunizations for adolescents- Combination 2 > 26%

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CY2019 reporting-only quality metrics

Metric

1. Avoidance of antibiotics in adults with acute bronchitis (AAB)

2. Appropriate treatment for children with upper respiratory infection (URI)

3. Statin therapy for patients with cardiovascular disease (SPC)- Received statin therapy

4. Statin therapy for patients with cardiovascular disease (SPC)- Statinadherence 80%

5. Comprehensive diabetes care (CDC): HbA1c <8.0%

6. Comprehensive diabetes care (CDC): Nephropathy

7. Cervical cancer screening (CCS)

8. Breast cancer screening (BCS)

9. Medication management for people with asthma (MMA)

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Background on assessment of quality metric sets for CY2019

• The State reviewed current PCMH core and reporting-only metrics to determine whether they should be retained, modified, and/or if new metrics were needed. Through this review, the State aimed to:

▫ Identify metrics that more effectively measure clinically meaningful processes and health outcomes

▫ Increase collective alignment across other programs and entities

▫ Effectively measure quality priorities in preventive and chronic care

• At the end of review, the State decided to maintain most of the current metrics across provider types with a few changes. Some of the changes include:

▫ Removal of five core metrics

▫ Addition of one new core metric

▫ Re-structure of five core composite metrics

▫ Addition of five reporting-only metrics

• The core and reporting-only efficiency metrics remain the same for CY2019

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Background on determination of quality metric thresholds for CY2019

• Next, the State evaluated several threshold models that took into consideration past and existing provider performance, as well as statewide and national performance on the 2019 quality measures.

• After careful consideration, the State established a threshold floor at the national Medicaid 25th percentile performance value. This means that all CY2019 core metrics have a threshold at or above this level of performance.

• The rationale behind this approach is to increase current provider performance and subsequently quality of care.

• The CY2019 quality metric thresholds include:

▫ Maintenance of current thresholds for three metrics

▫ Increase of current thresholds for 10 metrics to either the statewide performance average or national Medicaid 25th

percentile performance

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Adult BMI assessment (ABA)

• CY2018

▫ Adult and Family core metric

▫ Threshold set at > 60%

• CY2019

▫ Metric is removed from Adult core set. The metric still remains in the Family core set

▫ Also, this metric is added with the Weight assessment and nutritional counseling for children/adolescents (WCC)- BMI percentile only, to form new BMI composite metric in the Family core set

– Please note that the Weight assessment and nutritional counseling for children/adolescents (WCC) composite metric is no longer part of the Pediatric core metric set for 2019

▫ The ABA threshold increased to > 83%

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Antidepressant medication management (AMM)

• CY2018

▫ Adult and Family composite core metric

– Acute phase

– Continuation phase

▫ Continuation phase threshold set at > 40%Acute phase threshold set at > 55%

• CY2019

▫ Acute phase removed from Adult and Family core sets

▫ Continuation phase is more clinically relevant

▫ Continuation phase threshold maintained at > 40%

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Asthma medication management (MMA)

• CY2018

▫ Family and Pediatric core metric

▫ Threshold set at > 30%

• CY2019

▫ MMA metric moved to Family and Pediatric reporting-only sets

▫ Added new metric to Family and Pediatric core sets- Asthma medication ratio (AMR)

– Description: The percentage of members 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

– Threshold set at > 81%

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BMI composite (new metric)

• CY2019

▫ New composite metric for Family core metric set

▫ BMI composite metric includes:

– Adult BMI assessment (ABA)

Threshold set > 83%

– Weight assessment and counseling for nutrition for children/adolescents (WCC)- BMI percentile only

Threshold set at > 66%

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Comprehensive diabetes care composite 1 (CDC)

• CY2018

▫ Adult and Family composite metric

– Eye Exam


– BP control <140/90


– Nephropathy

Threshold set at >85%

• CY2019

▫ Composite metric is unbundled into stand-alone metrics for Adult and Family core sets

– Eye exam

Threshold increased to > 51%

– BP control <140/90


▫ Additionally, nephropathy is moved to reporting-only metric sets

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Comprehensive diabetes care composite 2 (CDC)

• CY2018

▫ Adult and Family composite metric

– HbA1c testing

– HbA1c poor control (>9.0%)

▫ HbA1c poor control (>9.0%) threshold set at < 50%HbA1c testing threshold set at > 85%

• CY2019

▫ HbA1c testing metric removed from composite for Adult and Family core sets

▫ Stand-alone metric: Comprehensive diabetes care (CDC): HbA1c poor control (>9.0%)

– Threshold set at < 47%

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EPSDT (composite for older kids)

• CY2018

▫ Family and Pediatric composite metric

– Well-child visits ages 7-11 years (custom)


– Adolescent well-care visits ages 12- 21years (AWC); included in Adult core metric set


• CY2019

▫ Composite metric for Family and Pediatric core sets

– Well-child visits ages 7-11 years (custom)

Threshold maintained at > 55%

– Adolescent well-care visits ages 12- 21years (AWC); Maintained in Adult core metric set


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EPSDT (composite for younger kids)

• CY2018▫ Family and Pediatric composite metric

– Well-child visits first 15 months (W15) Threshold set at > 45%

– Well-child visits ages at 18, 24 & 30 months Threshold set at > 34%

– Well-child visits ages 3- 6 years (W34); included as stand-alone metric for Family practices


• CY2019▫ Composite metric for Family and Pediatric core sets

– Well-child visits first 15 months (W15) Threshold increased to > 61%

– Well-child visits ages at 18, 24 & 30 months Threshold maintained at > 34%

– Well-child visits ages 3- 6 years (W34) Threshold increased to > 69%

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Immunization composite

• CY2018

▫ Family and Pediatric composite metric

– Childhood immunizations, Combo 3 (CIS)


– Immunizations for adolescents, Combo 2


• CY2019

▫ Composite metric is unbundled into stand-alone metrics for Family and Pediatric core sets

– Childhood immunizations, Combo 10 (CIS)- The % of children 2 years of age who were compliant on all of the following sub-measures: DTaP, IPV, MMR, HiB, HepB, VZV, PCV, Hep A, RV, and flu


– Immunizations for adolescents, Combo 2


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2019 TCOC Value for Low Volume PCMH Outcome Payment Formula

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$835

$234

PCMH

Health Link

Total Cost of Care (TCOC)USD PMPMCY 2015

• Statewide average TCOC used for calculation of outcome payments for Health Links and PCMH organizations with <5000 members

• Average is calculated using a capped mean:

▫ Mean is calculated across all MCOs

▫ Capped indicates members with TCOC>$100,000 are set to a cost of $100,000

▫ Capped most closely matches broader TCOC calculation

Statewide average Total Cost of CareThe average TCOC amount represents the average per member per month spend for a PCMH or THL member across all 3 MCOs and is included in the outcome payment formulas for low volume PCMHs and THLs.

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Proprietary and Confidential - For Internal Use Only

Update on average TCOC value for low volume PCMH outcome payment formulas for CY2019

• The State has decided to update the 2019 TCOC value for the low volume PCMH outcome payment formula to $242 to reflect the most up to date data on average TCOC we have for both programs (PCMH and THL).

50% Calculated50%$242 25%

Efficiency improvement percentage + Efficiency Stars

Outcome payment

Quality starsAverage cost of care PMPM

Maximum share of savings

#Attributed members

Member months

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Reporting Timeframes

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Performance report #1Cost Quality/Efficiency metrics

2018 (PY2) 2019 (PY3) 2020 (PY4)

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3Activity

Reporting period DOS

Report release

Reporting Timeframe- PCMH Wave 1








August 2018

Nov 2018

Feb 2019

May 2019

Aug 2019

Aug 2019

Nov 2019

Feb 2020

In August providers will receive two reports: the last performance report

for PY2 and the first report for PY3.

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2018 (PY1) 2019 (PY2) 2020 (PY3)

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3Activity

Reporting period DOS

Report release








August 2018

Nov 2018

Feb 2019

May 2019

Aug 2019

Aug 2019

Nov 2019

Feb 2020

In August providers will receive two reports: the last performance report

for PY1 and the first report for PY2.

Reporting Timeframe- PCMH Wave 2

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Questions?

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Updates on program guidance

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New guidance on NCQA timelines for acquired sites

• Some PCMH organizations have and/or are expected to acquire sites/practices which need to pursue NCQA recognition.

• The State has decided to set the following recognition timelines for newly acquired sites:

▫ If a participating PCMH organization acquires a site at any point after beginning program participation, then the newly acquired site is required to either maintain current NCQA recognition or pursue recognition within 15 months of the effective date of operations under the participating PCMH TIN.

▫ For example: If a participating PCMH acquires a site that is operationally effective as of 3/1/19, then that site must achieve recognition by 6/1/2020.

• The PCMH operating manual will be updated with this guidance and posted online.

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Funding associated with NCQA recognition

• The PCMH operating manual, NCQA requirement detail section has been updated with the following guidance:

TennCare will fund fees associated with the NCQA 2017 PCMH process from the point of enrollment up through the third check-in. If an organization does not achieve recognition for a site(s) after the third check-in, then they must purchase an additional check-in. Please contact NCQA for pricing details. Further, organizations may expect to pay for other fees that may be due under the NCQA PCMH recognition process such as requesting reconsideration and undergoing a Discretionary Audit. Please review NCQA's PCMH Standards and Guidelines for additional information on the fee schedule.

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Remediation process update for 2019

• In 2019, each MCO will manage their own remediation process for organizations identified as having poor performance. Each MCO will define the parameters for what is deemed as poor performance and issue communication to providers.

• The State will continue to maintain the remediation process due to failure to meet NCQA recognition requirement.

• The remediation process has been revised to reflect these changes in the 2019 PCMH provider operating manual.

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Navigant Update

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Navigant Update

• Navigant will continue to provide on-site coaching, host webinars, conferences, and collaboratives through 2019

• Navigant will begin conducting annual reviews with wave 1 and 2 PCMHs engaged in coaching

• Navigant’s support will end for both PCMH and THL January 31, 2020

• At that point, on-site coaching/support will be provided by the MCOs

Upcoming learning opportunities

• December 13: PCMH Navigant webinar “Behavioral Health and Primary Care and PCMH Distinction in Behavioral Health Integration”, 11-12 CST

• Please note: The December regional collaboratives have been cancelled

• Dates for 2019 conferences: February 26th (West), 27th (Middle) and 28th

(East)

Questions?

Documents

STATE OF TENNESSEE...–Well-child visits ages 3- 6 years (W34); included as stand-alone metric for Family practices Threshold set at > 65% • CY2019 Composite metric for Family and